Owning the Trauma Bay: Teaching Trauma Resuscitation to Emergency Medicine Residents and Nurses through In-situ Simulation

Audience The following two cases were designed to address learning objectives specific to interns, junior residents, and senior residents in emergency medicine, as well as trauma-certified emergency nurses. Introduction Traumatic and unintentional injuries account for 5.8 million deaths across the globe each year, with a high proportion of those deaths occurring within the initial hour from the time of injury. This “golden hour” begins in the pre-hospital setting yet is predominantly spent in the emergency department (ED).1 Being able to effectively manage the multidisciplinary team required to care for trauma patients is crucial to providing timely and appropriate care. In-situ simulation, where the learning case is moved out of the simulation lab and into the typical workplace, has emerged as a powerful training tool for improving care-systems and team dynamics.2,3 Multiple specialties have shown in-situ simulation to be an effective strategy to teach both educational content as well as critical procedural and communication skills.4,5 In-situ simulation training has also been applied with similar success to trauma management, allowing for the simultaneous education of different learners with different roles in trauma resuscitations.6,7 We present two in-situ simulation cases with specific educational objectives and feedback mechanisms that allow for easy implementation of a cost-effective approach to training multidisciplinary emergency medicine providers in trauma management. Educational Objectives: The core objectives of these simulations center on effective teamwork and communication during trauma resuscitation of a critically ill patient. Both cases are designed to include maneuvers that require coordinating team members’ actions during a stressful situation such as rolling a vomiting patient with a head injury and applying a binder to an unstable pelvic fracture. While the cases are largely focused on improving communication, salient learning points on emergent management of intracranial hemorrhage and unstable pelvic fractures are highlighted during the encounter. In addition, this simulation module allowed for the practice of graduated level of responsibilities amongst residents in the trauma bay. Educational Methods Two in-situ simulation cases were run with the same group of learners using standardized patient actors as patients and functional medical equipment in actual rooms in the emergency department to recreate a realistic experience. These groups were composed of emergency medicine residents with at least one intern, one junior resident, and one senior resident in each group as well as a bedside nurse, documenting nurse, and simulation instructor. Each case was followed by a group debriefing session using multiple sources of feedback. Standardized patients, bedside nursing, and simulation instructors were all incorporated into the feedback and debriefing process. Research Methods Pre- and post-simulation surveys were given to participants to assess their confidence in participating and leading trauma resuscitations. Results A total of 29 emergency medicine residents completed both our pre- and post-survey. We found that less than half of those surveyed felt comfortable leading trauma resuscitations. After the simulation scenarios, an overwhelming majority agreed that they felt more prepared to run trauma resuscitations as a result of the simulation experience. In their free response comments participants also remarked upon the ability of in-situ simulation to better foster realistic learning opportunities with regards to communication and resuscitation management. Discussion Based on our survey results, we found that a large portion of our participants did not feel comfortable leading trauma resuscitations. The post-survey and the free-text responses collected during the case scenarios show that our in-situ simulation proved to be an effective way to teach various types of learners new trauma roles and optimize high-stress communication during resuscitations. The use of in-situ simulation provides an effective and easily adapted framework even for those outside of academic centers and simulation labs while also offering an opportunity for multidisciplinary growth. Regular incorporation of similar learning opportunities into resident, nursing, and staff education can lead to better communication and teamwork during in-vivo patient encounters. Topics Trauma resuscitation, in-situ simulation, code leader education, communication training.


Associated content (optional):
We have included the form we used for nurse documenters to evaluate the team.

Results and tips for successful implementation:
We performed both a pre-and post-survey of the emergency medicine residents who participated in the simulations, with a total 29 respondents. The pre-survey asked participants to assess their level of comfort leading trauma resuscitations, with 19% "very comfortable," 26% "slightly comfortable," 14% "neither comfortable nor uncomfortable," 5% "uncomfortable," and 36% "very uncomfortable." On the post-survey 45% stated that they "Strongly Agreed" that the simulations had helped prepare them to be better able to run trauma resuscitations, while another 45% "Slightly Agreed" with the statement. There were 7% of participants who were "Neutral" to the statement and 3% who "Disagreed." When we analyzed the free text comments, we noted several themes. Two of the 23 comments indicated that the participants preferred the in-situ format to the traditional simulation center. Another two of 23 comments referenced systems issues they learned or reinforced during the simulations. Participants felt more confident or prepared after having participated in these simulations (4 of 23 comments), and the most commonly mentioned feedback involved having a better appreciation for the team captain role (5 of 23 comments). Even those who did not act as team captain felt they had "some insight into role delegation and relative responsibilities." We were encouraged by these results and believe the scenarios and learning objectives are best achieved when utilized with a group of varying levels of training. We used a PGY-1 resident to perform the trauma survey examination, a PGY-2 resident to perform procedures/point of care ultrasound, a PGY-3 resident to serve as the code leader, a trauma-certified bedside nurse, and a registered nurse to handle documentation similar to realtime ED workflow. Additionally, if present at your institution, an emergency department pharmacist can be recruited to help dispense medications during the scenarios and discuss the pros and cons of different medical management for increased intracranial pressure in case 1. The case scenarios allow for junior residents (PGY-1 and PGY-2) to perform trauma management (eg, objectives 3 and 4) directed by the senior resident (PGY-3). The case scenarios also allow for optimizing communication delivery between senior physicians and nurses during resuscitations with a specific objective of improving teamwork skills (eg, objectives 1 and 2). Ultimately, the debriefings allow for all involved learners to be exposed to all of the learning objectives for different levels without feeling overwhelmed in each of their respective roles. In our module, we partnered with nursing leadership to provide nursingspecific trauma continuing education. The modules met nursing-specific educational goals such as managing the rapid fluid infuser, which allowed for increased nursing participation. We utilized a specific feedback form for nursing documenters to increase sources of evaluation and augment debriefing (see associated content).
An added benefit of using in-situ simulation rather than a simulation lab was that we were able to perform both cases back to back in five different rooms simultaneously in an ED zone prior to daily opening during the resident weekly educational conference. All residents went through the learning objectives at the same time. We were then able to hold a large group debriefing session after the individual case debriefs, which allowed each group to share their main learning points. Based on our post-session surveys, both nurses and residents enjoyed the active and interdisciplinary learning as well as the in-situ format, which had not been used frequently in their educational conference up to that point. Additionally, nursing staff did not traditionally attend the resident education conference and this provided an opportunity to bring their perspective to resident education.
While this format did bring its own advantages, we realize that for many it is not feasible to always count on a specific area of the emergency department to be empty or to have all residents free at the same time. One alternative option to the location is to consider using a simulation room or simulation center, but to keep the equipment used during the simulation as close to that encountered in your emergency department as possible such as real patient actors, backboards, ultrasound machine, and procedural equipment. Another possibility is to use a conference room or classroom, again with as much real-life equipment as possible, because the educational benefit will still be achieved from the interpersonal interactions and troubleshooting required by the cases. If all residents are not available at the same time, or there is not a space large enough to accommodate them all at once, the scenarios can be performed by one group at a time and then rotated, either throughout the same day, or while performing other group learning activities, or across multiple weeks. Additionally, filming each group's simulation can be a way to highlight key takeaways and educate residents or nurses who may not be able to make it in person.

Background and brief information:
The patient arrives on a backboard and with c-collar immobilization performed by EMS to a Level 1 trauma center with one peripheral IV established (taped to arm).

Initial presentation:
The patient is alert and speaking in full sentences although is mildly confused about the events surrounding the fall. The patient has normal vitals.
How the scene unfolds: As the primary and secondary survey progress, the patient becomes more confused and somnolent. After being rolled to assess the patient's back as part of the primary survey of exposure, the patient feels nausea. Upon rolling back, the patient begins to vomit and gag requiring the patient to be rolled again for oral airway suctioning. At this point, the patient becomes minimally responsive. The learners must recognize the need to secure the patient's airway. If they do not proceed with intubation, the patient becomes unresponsive and hypoxic until the procedure is accomplished successfully. Learners should articulate the need for anticoagulation reversal and the management of increased intracranial pressure (ICP). The latter may be achieved with either hypertonic saline or with mannitol before or after CT imaging is performed. identification is best done prior to the patient arriving, with the team leader announcing their name and role aloud and asking everyone in the room to do the same. Another helpful tactic is for the team leader to stand at the foot of the bed and not perform any other task during the resuscitation. -Were the appropriate tasks performed in a coordinated, logical fashion? Why or why not? This can often be difficult during a trauma survey as certain interventions need to be done prior to completion of the survey. As the primary survey moves along from airway, breathing, circulation, disability, and exposure (A-B-C-D-E) any life-saving intervention should be performed once the need is identified and prior to moving on to the next element of the survey. Definitive management of issues identified in the primary survey should take priority before beginning the secondary survey.

Medical Management:
epidural hematomas can present with a "lucid interval" during which the patient appears well. However, they can quickly decompensate as the hematoma expands elderly head trauma patients need to be monitored closely, especially those on anticoagulation vomiting trauma patients should be log rolled onto their side to avoid the risk of aspiration care should be taken when intubating head injury patients to maintain in-line cervical spine stabilization and avoid hypoxia and hypotension patients on warfarin should have their INR checked when they present as trauma patients a life-threatening intracranial bleed in a patient on warfarin should be reversed with four-factor prothrombin complex concentrate for rapid effect. Vitamin K can be given but will take time to have any effect, and fresh frozen plasma (FFP) can be considered if four factor concentrate is not available; however, FFP takes longer to administer due to thawing and rate of administration hypertonic saline or mannitol can be used emergently to decrease intracranial pressure -The head of the bed should be elevated to 30 degrees in patients with intracranial hemorrhage, assuming thoracic and lumbar spine precautions are not in effect hyperventilating to regulate cerebral blood flow is of questionable benefit and should only be performed as a temporizing measure

Assessment Timeline
This timeline is to help observers assess their learners. It allows observer to make notes on when learners performed various tasks, which can help guide debriefing discussion.

Case Description & Diagnosis (short synopsis):
This is the case of a road cyclist who crashes while going downhill at moderate speed. The patient presents with large scattered abrasions and thigh pain causing reluctance to move the left leg. As the survey progresses, the patient becomes more tachycardic and hypotensive, and learners should pause to obtain a screening pelvic x-ray which reveals an open book pelvic fracture. The team should apply a pelvic binder (either a sheet with towel clips or a commercially available device). Failure to bind the pelvis will result in continued hemodynamic decompensation. The patient's blood pressure will stabilize but should remain low, prompting recognition of the need for a massive transfusion protocol and intubation. Procedure physician should be performing FAST on standardized patient (normal).
If patient has not yet been put on monitor, documenting nurse should ask if they should get vitals.
If not performing FAST (Focused Assessment with Sonography for Trauma) have documenting nurse ask if they should be performing one.
If they assess for pelvic instability, instructor announces there is movement to lateral compression and scenario skips to 02:10.
Same as above.
2:00 Secondary survey proceeds with patient supine. If team tries to roll patient prior to completing all other aspects of secondary Patient does not want to move lower extremities during secondary survey due to pain. Has normal exam to palpation and inspection of lower extremities.
Same as above. Patient remains with eyes closed and short answers.

OPERATOR MATERIALS
If team does not discuss intubation, instructor can prompt assuming role of IR attending.
Same as above.
14:00 Patient intubated (ETT taped to side of face), all medications called for and delivered by RN.
RN should prompt for sedation orders if not asked for by team leader.
Same as above.

End of Case
Sedation ordered; patient readied for transfer to IR suite.
If no sedation ordered and short acting paralytic given, can begin to jerk until sedation called for.
Case ends when patient is properly sedated and instructor announces that IR suite is ready for patient. identification is best done prior to the patient arriving, with the team leader announcing their name and role aloud and asking everyone in the room to do the same. Another helpful tactic is for the team leader to stand at the foot of the bed and not perform any other task during the resuscitation. -Were the appropriate tasks performed in a coordinated, logical fashion? Why or why not? This can often be difficult during a trauma survey because certain interventions need to be done prior to completion of the survey. As the primary survey moves along from airway, breathing, circulation, disability, and exposure (A-B-C-D-E), any life-saving intervention should be performed once the need is identified and prior to moving on to the next element of the survey. Definitive management of issues identified in the primary survey should take priority before beginning the secondary survey.

Medical Management:
-Pelvic stability should be assessed during a trauma survey. If instability is noted, subsequent exams should be deferred. -Pelvic fractures can lead to significant retroperitoneal bleeding due to a large number of bony fragments and shearing against vasculature in the pelvis. Retroperitoneal bleeding may result in a negative FAST.
-Binding of the pelvis should be performed as soon as an unstable pelvic fracture is suspected to minimize bony fragment movement and decrease the potential space for blood to pool. -Pain management in the hypotensive trauma patient can be difficult because opiate pain medication usually results in some lowering of blood pressure. At the same time,